5555 Eglinton Ave W, Etobicoke, ON, M9C 5M1
Phone: 416-626-0473

Consent Form for New Patient Exam, X-rays, Dental Fillings, Hygiene Cleaning, and Local Anesthesia

Treatment Description

As a new patient, I understand that a comprehensive dental examination will be performed, which may include:

Review of medical and dental history

Visual examination of teeth and gums

Digital or traditional X-rays

Intraoral photographs (if needed)

Dental hygiene cleaning (scaling and polishing)

Administration of local anesthesia if required

Dental fillings using composite (tooth-colored) or amalgam materials if cavities are diagnosed

Purpose of Treatment

The purpose of the examination and X-rays is to evaluate my oral health and detect any problems that require treatment. Dental hygiene cleaning helps remove plaque, tartar, and stains, improving gum health. Dental fillings are intended to restore teeth affected by decay or minor fractures and to prevent further deterioration. Local anesthesia may be administered to reduce discomfort during treatment.

Treatment Alternatives

I understand that alternatives may include:

No treatment (with potential worsening of oral health)

Delaying treatment (with risk of pain, infection, or more complex procedures later)

Extraction or other restorative procedures if fillings are not suitable

Risks and Complications

I understand that:

Fillings may cause temporary sensitivity to hot, cold, or pressure

A filling may not resolve all symptoms, and further treatment (e.g., root canal) may be required

Cleaning may result in temporary gum soreness or bleeding

Deep cleaning may reveal sensitivity due to exposed root surfaces

X-rays involve minimal radiation exposure and are performed with protective measures

Local anesthesia may cause temporary numbness or mild allergic reactions

Post-Treatment Instructions

I will follow instructions provided by the dental team, including:

Avoid chewing hard foods until numbness wears off

Report any prolonged pain, sensitivity, or discomfort

Maintain good oral hygiene and attend regular dental visits

I have had the opportunity to ask questions about the dental examination, X-rays, cleaning, fillings, and local anesthesia. I understand the procedures, risks, benefits, and alternatives. I voluntarily consent to the proposed treatment.

Consent Form

Sunrise Dentistry

Consent Form for New Patient Exam, X-rays, Dental Fillings, Hygiene Cleaning, and Local Anesthesia

Treatment Description

Purpose of Treatment

Treatment Alternatives

Risks and Complications

Post-Treatment Instructions

Consent

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